Revocation of Designation of Attorney In Fact

• Legal Form Number: I-312A
• Section: U.S. Immigration and Customs Enforcement
• Issuer: U.S. Immigration and Customs Enforcement

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

REVOCATION OF DESIGNATION OF ATTORNEY IN FACT

ICE Form I-312A (3/23) Page 1 of 2

OMB No. 1653-0041

Exp. 02/28/2026

I,, ofas principal

(Obligor) (Address)

and obligor on Cash Bond No. , in the amount of $, executed in favor of

, appointed ,

.

(Attorney in Fact’s Name)(A Number)(Alien's Name)

, A No.

, to be my attorney in fact and to receive the

(Attorney in Fact’s Address)

proceeds of this bond once it was breached or canceled. I appointed this individual on

of

(Date)

Today, on this date,, I hereby revoke and terminate this appointment. This revocation will not be effective unless

it is properly notarized, and until the original form is received by the Bonds Section, Financial Operations – Burlington, U.S. Immigration

and Customs Enforcement, P.O. Box 5000, Williston, VT 05495, its validity confirmed, and it is entered into an ICE database. If this

revocation is invalid, the Bonds Unit will return it with a brief explanation of why it is not acceptable.

IN WITNESS WHEREOF, I have set my hand and seal on theday ofin the year.

Signature of Obligor (Principal) (Sign in ink)

Obligor Information (Please Print)

TIN or SSN:

Name:

Address:

On theday ofin the year

County:

State of:

before me personally came

(Obligor) to me known and known to me to be the individual described in and who executed the foregoing instrument and

acknowledged to me that s/he executed the same for the use and purpose therein contained.

Notary Seal

Notary Public, State of:

My commission expires:

REVIEWED AND ENTERED INTO ICE DATABASE

Date:

(For an Obligor to Revoke a Previous Appointment of an Attorney in Fact made using ICE Form I-312)

Do Not Write in this Space - Agency Only